Study On Framework Of Electronic Clinical Record Documents And Standardization Of Data Elements

Today reformation of medical policy and medical insurance have made the hospital information construct face some problems of communication due to lack of uniform standards. In fact, information standardization had been the main obstacles for hospital information development. Health information resource sharing is the core issue which should be solved for hospital information construct. And the core problems should be solved for health information resource sharing are uniform standard documents including electronic clinical records such as electronic patient records. The degree of health information sharing depends on uniform standards, especially the clinical information standards. With the development of harmonious society and people-oriented idea, hospital medical service must focus on customers or patients and quality of service must be improved. And hospitals must quicken the hospital information system progress in order to boost communication of patients information and patients information sharing, and lead to patient information sharing between hospitals. To achieve the goals above, scope of clinical information, information form, communication format must be specified and unified. Clinical decision must base on accurate, relevant, legible, ideal and complete information. And the information attain through collecting, sorting, analyzing, abstracting data. Translating data into information of decision-supported often need a good many programs, but not all people relating to capturing, recording, sorting, transmitting, analyzing, using data can understand the actual value of the data. During the clinical service a great deal of information are produced, and what kind of information should be collected to meet different information users. Information users often require the information with some degree of details or specifically format such as the process of data producing, definition and representation. So clinical data model must be established to guide collecting, recording, sorting, transmitting, analyzing, using data, and to make people have agreed unified concept of data, to transform the data into useful information. All these above will collect high quality data to meet the whole clinical health information system's need for data utilization. The clinical information content relates to information that needs to be captured, stored and viewed to support the objective of improving delivery of health care and better quality of care.This paper is focus on the framework of electronic clinical record documents and standardization of data elements. The main contents and results of this study include the following:(1) Established clinical information framework and model. The clinical information framework provides a set of high-level concepts that encompass and describe healthcare in a broad sense. The Clinical Information Model (CIM) is a simplified representation of the domain of health and healthcare for the individual. It includes a hierarchical classification and a set of definitions of concepts and concept relationships including the event, event participants and other concepts that influence health. The CIM illustrates the taxonomy of high level health concepts that can be used as the criteria for determining what constitutes a clinical event and what information should be associated with the event to describe the consumer or patient's health status at that time. Its purpose is to assist in defining the scope, granularity and organization of electronic health record content. Based on references to some foreign health information frameworks and broad consultation we established a clinical information model which encompasses: health status, participants, events (both healthcare acts and life incidents), risk and preventative factors, clinical knowledge and objects. There are seven clinical information model diagrams represented by using UML.(2) Some clinical event summaries specifications were proposed. Each healthcare event generates information pertaining to the health of a consumer or patient. This information is then captured, either in whole or in part, and augmented or altered by the clinician(s) involved. Clinical event summaries can make the clinician(s) involved capture the information pertaining to the health patient, the collection of clinical event summaries constitute shared EHR. In this paper, five clinical event summary prototypes such as Hospital Discharge, Health Status description, Medical Consultation, Diagnostic Investigation–Imaging, Diagnostic Investigation– Pathology were studied.(3) Clinical data group specification. A data group is a composite data structure (a collection of data elements or smaller data groups) for holding related items of information. A data group organizes the data it holds. In this paper, eleven clinical data group prototypes such as Adverse Reaction, Alert, Immunization, Observation, Reason for Encounter, Diagnosis, Clinical Intervention, Pathology Episode, Diagnostic Imaging,Clinical summary,and Medication were studied, and their prototypes were proposed respectively .(4) Application of data elements in clinical information system. Data element standard is one important methodology for standardizing data itself. Data element standardization can help to construct effective data model and information sharing and exchanging. It plays an important role in information standardization.(5) Data integration and representation of electronic clinical record documents based on XML. Owning to XML having many merits, using XML can solve the problems of storing, transferring, presenting and processing the electronic clinical record documents, and some examples were given.(6) Clinical data elements harmonization with National Health Data Dictionary(NHDD). NHDD is national health meta data repository, whose aim is to make the users attain data elements and meta data. Meta data describing data elements in the clinical information model can refer to the meta data defined in NHDD, and we established their harmonization relationship.The process of constructing Clinical Information Model, Clinical event summaries, Clinical data groups and data element standardization is very complicated and difficult. They have close relationship between them, and they are from macro to microcosmic. Results of this paper will promote the clinical information standardization development.